20 March 2010

Dr Grumble has been wondering about the sanity of those planning the latest health service initiative: swingeing bed cuts. There seems to be a new belief amongst NHS managers that hospital doctors are admitting patients who could be managed by their GP at home. This is one of those quirky managerial beliefs that has recently become propagated from somewhere on high. Who starts these concepts Dr Grumble has no idea. They arrive seemingly from nowhere and all of a sudden NHS managers throughout the realm slavishly follow the latest edict like flocks of mindless sheep. Whatever the idea is, however batty, the NHS manager will believe it implicitly and without question. Evidence-based management is not in the health service lexicon.

The approach has something akin to a religion. NHS management has much more to do with blind faith than reason. Consequently today's unquestioned mantra is that hospital beds need to be cut and that patients can be managed 'closer to home'. To be fair, there are certainly patients in hospital who should not be there. Most of them needed to be there when they were ill but then cannot go home because they can no longer manage without more social support. But getting that social support promptly can be, to say the least, a challenge.

Dr Grumble's ward round today was a long affair. Five whole hours without a break. He saw all sorts of patients. Some were in their teens. Most were elderly. Some were very rich. Most were quite poor. Some were very ill. Some were not so ill. One was not acutely ill at all. He was an elderly man who lives alone. He struggles to manage. He has some medical problems including long-standing ulcers on his legs. The nurses who look after him phoned the patient's GP yesterday and said that he needed to go into hospital. Yesterday was Friday. Things can seem worse on a Friday.

The GP did not go and see the patient. Perhaps he should have. On the other hand, quite possibly it was not going to change the outcome. If the nurses were not happy that the patient could be looked after at home what was the GP to do? Certainly the GP was acquainted with the patient and knew the situation. And, rightly or wrongly, he sent the patient in. The patient was dutifully clerked by a junior doctor and the patient was admitted to the Grumble ward. The patient was presented to Dr Grumble. Dr Grumble assumed that the ulcers on the ankles must be pretty grim and that that was the reason for the patient's admission. But when Dr Grumble saw the patient he was quite well and the ulcers were clean. There was nothing the hospital could do to make this patient any better. The patient did not want to be in hospital and was keen to go home. But because he is so old and generally frail he really cannot manage at home. Hospitals are open all day and all night and take all comers. There is nowhere else for these people. It has been like this for ever. And our managers have done nothing about it.

Posted by
Dr Grumble

12 comments:

I wonder why the nurses didn't think he could be looked after at home? In Wales, as a GP, I can access one week of emergency social care to prevent this kind of thing happening. There is meant to be a medical reason for the sudden change of circumstances. I have used this service several times and it has helped me avoid the situation you describe. By the way, I have to have seen the patient myself that day, or the day before. And the service does seem to be continued after the week if necessary.

I've been looking to see if I can find any links about this scheme online. It seems that it might in fact be a Caerphilly only programme, funded by 'Wanless' money. (http://www.wales.nhs.uk/documents/wanless-review-e.pdf)

So Wanless, former Chairman of The Northern Rock's Audit and Risk committee, reached Wales too. It is very strange that the government chose a banker who didn't even know enough about banking to keep his bank solvent to advise on something he knew even less about.

I had a patient admitted to CCU the other week with chest pain. All turned out fine - no new pathology identified - and she was teed up for discharge.

She was on the waiting list for a nursing home and social services - even though nothing had changed about her or her circumstances - suddenly decided that she was not able to go home as they couldn't look after her. She's now on the ward awaiting NH placement, which will likely take months.

Anne Marie, alas I cannot say that I have EVER been able to access this service in North Wales.(Rapid Response Team) No matter how much I try, no matter how "social" the problem the service always bounces the referral after asking me to fill in a 4 page "unified assessment", so much so that I now have to ask patients to ask for it - it seems to work for them.

Social services hiding behind lengthy forms and finding various reasons not to take responsibility for a problem that is theirs is a all too common. But it is good to know that there is at least a part of the UK where there is the possibility of summoning emergency social care. And it is interesting to learn that this is in Wales, where the NHS was conceived:

As I say this may be a Caerphilly-only service. I certainly don't have to go through a lengthy form. I phone a co-ordinator on their mobile number and advise them of the situation. They ask me how many times each day the patient needs to be seem and they arrange the service- for the same day if I call early enough. I do hope the service does not disappear soon.

Dr Grumble,I was at a lecture by the wonderful Dr Tudor-Hart last week in Cardiff University. Although he has retired many years (he is now 83), a mini-bus load of his old patients came along to hear him speak. I regretted not recording it as soon as he started speaking. His main gift seems to be generosity of spirit. And I particularly liked his comment that patients are not consumers, but can be producers if given the chance.

People like Julian Tudor Hart are, to say the least, rather out of fashion these days. Certainly in England. Dr Grumble was aware of this lecture from this source.

One of the Grumble children could have gone but Dr Grumble thought that he probably wouldn't bother so did not tell him. Perhaps that was a mistake but the last time Dr Grumble recommended a lecture to another of the Grumble children he didn't bother to go. The lecture was given by a man whose blood had once literally boiled. It wasn't recorded and it will never be given again. Never ever.

Old people (or are we supposed to call them older people now?) are worth listening to. And you need to be sure you listen to them while you still can. Teenagers think they know everything and can be dismissive of the old. As you get older, very gradually, you learn that you do not know everything. And by the time you are Grumble's age you realise that you will never know more than a tiny proportion of what there is to know. Hopefully the Grumble child who chose not to go to the lecure Dr Grumble recommended has learnt his lesson. He now occasionally reads this blog. This comment is for him. I wonder if he will read it.

Actually the Grumble child concerned is a 20-something but his younger brother, a teenager, is even worse for knowing it all (and twenty-something does not actually trip off the tongue).

I can remember being the same - just as Oscar Wilde could.

It is actually only towards the end of my working life that I realise that those ahead of me about to retire have the most knowledge of all. Hardly surprising when you think about it but somehow it doesn't seem that way when you are young.